The Effects of Racial and Ethnic Differences or Similarities on the Therapeutic Alliance

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1 46 College of Education The Effects of Racial and Ethnic Differences or Similarities on the Therapeutic Alliance Rafael O. Leite & Paul Peluso The increasing diversity of the United States raises the probability that a therapist will encounter clients with a different racial or ethnic background than their own. Thus, evaluating the relationship between racially or ethnically similar or different therapists and clients is essential in producing effective cross-cultural therapy. The objective of this study was to determine any significant effects that racially or ethnically similar or different clients and therapists have on the therapeutic alliance. The alliance was measured using the Working Alliance Inventory (WAI) for both the clients and therapists at a university counseling center to evaluate the influences on the overall therapeutic alliance. The results of the study were that neither therapists nor clients rated the therapeutic alliance significantly different regardless of whether the other person was of a similar or different racial and ethnic background. However, there were significant differences in how male and female therapists rated the alliance. As cultural diversity increases across the United States, it is important to explore how it impacts various facets of our society. The U.S. Census (2015) reported that by 2044, the current minority racial and ethnic groups will become the majority in the United States. In addition, by 2020, approximately half of all children in the country will have at least one minority parent (U.S. Census, 2015), which suggests that growth in diversity is happening even sooner than one may think. An area where it is especially important to study these changes is in the mental health and counseling services field. Diversity of cultures has received more attention in the therapy literature over the past several years, and its importance in the field will only continue to grow as the country experiences a burgeoning of different backgrounds. Studies demonstrate that minorities are more likely than White Americans to dropout and underutilize mental health services in the United States (Casas et al., 2002 as cited in Vasquez, 2007; Wintersteen, Mensinger, & Diamond, 2005). This leads us to question and investigate the reasoning behind these imbalances in mental health services. One way to explain this issue is to look at the elements of the mental health services itself, particularly the relationship between the therapist and client. In the counseling setting, the therapeutic alliance refers to the bond between a therapist and a client and the manner in which they work collaboratively and effectively (Asnaani & Hofmann,

2 ). Furthermore, the formation of a strong alliance in the beginning stages of therapy has been directly related to positive outcomes (Horvath, Del Re, Fluckiger, & Symonds, 2011). This strong relation between the alliance and outcomes in therapy can be used to assess the therapeutic relationship in diverse therapist-client dyads. This study examined the therapeutic alliance and how racial and ethnic differences and similarities between therapists and clients can impact this crucial aspect of therapy. MULTICULTURAL COMPETENCE Multicultural competence has received increased attention in the education of prospective therapists and counselors. Mental health counselors and psychotherapists are expected to take on cases within the boundaries of their competence, based on their education, training, [and] supervised experience (American Counseling Association, 2014). Therefore, it is important for therapists to feel comfortable enough in their abilities to be able to effectively provide the treatment necessary for the client. Cultural competency refers to the ability of a therapist to understand, handle, and provide proper therapeutic treatment to a client of a culture different from his or her own (DeAngelis, 2015). Not only is conducting culturally sensitive therapy a standard according to the American Counseling Association, but it is also integral for positive and successful therapeutic outcomes (DeAngelis, 2015). It is critical for mental health providers to be both culturally aware and sensitive when addressing a client of either the same or different cultural background in order to provide the best possible client-centered treatment to improve overall well-being. It has been reported that minority college students do not use university counseling centers and mental health services as much as their White counterparts (Brinson & Kottler, 1995 as cited in Constantine, 2002). This could be due to the negative perception or stigma associated with mental health treatment that is present among their culture or perhaps unfamiliarity with the topic (Constantine, 2002). Therefore, it is of significant value that therapists possess multicultural competence in order to best deal with issues of minority clients in a culturally appropriate way. The client s perception of a therapist s multicultural competence can reveal important information regarding their views of therapy and how their cultural identity is dealt with in therapy. Constantine (2002) reported that the clients perception of their therapists overall competence and multicultural competence predicted their satisfaction ratings of therapy. This suggests that the overall competence of a therapist, which includes an effective working alliance, can contribute to the effectiveness of therapy in minority clients. It is important to consider the cultural values and traditions of a client when it comes to providing mental health services. For instance, in Latin- American culture, there tends to be more collectivistic and familial perspectives, whereas Americans tend to be more individualistic and independent. These differences in perspectives can be the cause of the underutilization and negative perception toward counseling and mental health services among Latino Americans in the United States (Peluso, Miranda, Firpo-Jimenez, & Pham, 2010). While it may be seen as more common for an American to seek counseling, Latinos may be expected to use their family or core social groups for support (Carter, Yeh, & Mazulla, 2008 as cited in Peluso et al., 2010). Being able to recognize this cultural difference can ensure that a therapist is providing culturally sensitive treatment that is most appropriate for his or her client.

3 48 THE THERAPEUTIC ALLIANCE The therapeutic alliance is a significant part of the overall predictors of successful outcomes in therapy (Horvath et al., 2011). The therapeutic alliance is defined as the bond between a therapist and a client and the ability for them to work collaboratively and effectively in therapy (Asnaani & Hofmann, 2012). The therapeutic relationship is a part of the common factors theory that explains the most important factors for effectiveness in therapy. (Horvath et al., 2011). The current study incorporates the common factors theory into the investigation of how the therapeutic alliance factor interacts with multicultural competence in counseling to produce effective therapeutic outcomes. The strong relationship between the alliance and therapeutic outcomes is important to consider when analyzing the therapeutic alliance. The formation of a strong alliance in the beginning stages of therapy is directly related to positive outcomes (Horvath et al., 2011). The underutilization and high dropout rates in mental health services among minorities is an issue that must be further examined. There may be many possible explanations for this finding, with one of them being that clients of racial and ethnic minorities do not have a strong alliance with their therapist (Vazquez, 2007). RACE, ETHNICITY, AND THE THERAPEUTIC ALLIANCE It is important to know if differences in cross-cultural counseling or therapy are even acknowledged in order to better understand the role that these differences play in the overall therapeutic outcomes. It is speculated that these discrepancies could be caused by inadequacy in considering various differences among the therapist and client, including but not limited to cultural awareness, cultural knowledge, and cultural presence in development (Maxie, Arnold, & Stephenson, 2006). Maxie et al. (2006) examined whether ethnic and racial variations between therapists and clients are discussed in the therapeutic setting. Out of the 689 psychologists surveyed in the study, nearly 85% of them stated that they had addressed cultural differences between themselves and their clients at least once in the past two years. However, despite this high percentage, on average, the therapists reported that they discussed these cultural differences in only approximately 43% of their total experiences with culturally dissimilar clients. A study by Chang and Berk (2009) assessed the clients perceptions of cross-racial therapy regarding the specific factors of the relationship that predicted satisfactory and unsatisfactory therapeutic experiences. In the study, 16 clients from racial or ethnic minority groups were in therapy with a White therapist, and the overall satisfaction of each client was recorded. The clients in cross-racial therapy who reported being satisfied, were shown to believe that the therapist focused on the client s primary needs and helped in achieving goals. This ties in directly with the therapeutic alliance, which emphasizes the mutual agreement of goals created for the client (Chang & Berk, 2009). Wintersteen et al. (2005) explored the differences between race and gender among therapists and clients and the relationship with the therapeutic alliance, particularly among adolescent patients. They reported that clients who had a therapist of the same race, stayed in therapy for a longer period of time. The results showed that 55% of racially different therapist-client dyads completed at least twothirds of the treatment, while 79% of the dyads with the same race completed that same amount of treatment (Wintersteen et al., 2005). They also found

4 49 that Caucasian therapists rated their working alliance with clients of the same race higher than those of a different race. In addition, minority therapists reported a higher therapeutic alliance with clients with minority backgrounds than with Caucasian clients. However, overall, the ratings of the clients were not significantly different for racially similar or different therapists. These results demonstrated the opportunities for improvement in multicultural competent counseling due to some of the variation found among similar or different backgrounds within therapist-client dyads. This purpose of this literature review was to investigate previous studies about racial and ethnic differences in therapists and clients, specifically in the context of the therapeutic alliance. This study combines the concepts of multicultural competence and the therapeutic alliance in counseling to evaluate their interaction. Although researchers have previously conducted studies into cross-cultural therapy or the alliance, there have not been many studies that provide a comprehensive look at these two important parts of counseling, specifically in the university setting. For example, although the study from Wintersteen et al. (2005) examined the effects of racial differences on the therapeutic alliance, there are limitations that do not reveal the whole picture. That study focused on adolescents in substance abuse treatment, while the present study looked at college students at a university counseling center. This current study aimed to amass the important points presented in the literature and focus on certain aspects that will be useful in attempting to answer the original research question. The purpose of the current study was to investigate any significant effects that differences or similarities in therapist-client racial and ethnic backgrounds may have on the therapeutic alliance. The current research attempted to fill the gap in the literature regarding the influences that racial and ethnic matching have on the therapeutic alliance, specifically among college students seeking mental health services at a university counseling center. The results of the research can be used to show the importance of multicultural competence in counseling relationships in order to provide the best outcomes for culturally diverse clients. It was hypothesized that clients seeing therapists with a similar racial and ethnic background to their own will rate the alliance significantly higher than clients who have a therapist with a different background. Additionally, therapists with clients from a different background will rate the alliance significantly lower, while therapists with clients who share similar racial and ethnic backgrounds will rate the alliance higher. METHOD Participants This study involved participants from the Counseling and Psychological Services Center from a public university in South Florida. There was a total of 48 participants; Forty-one of the participants (10 males, 31 females) were clients and seven of the participants (2 males, 5 females) were therapists. Both therapists and clients consented to participate in research studies. The participants were chosen because their demographic data along with instrument data for both therapist and client were available to the researchers. The ages of the client participants ranged from 17 to 34 years with the average age of the client population being years. The racial and ethnic backgrounds of the client population sample included: 24 identified as Caucasian (58.5%), eight identified as Latin American/

5 50 Hispanic (19.5%), four identified as Caribbean (9.8%), three identified as African American (7.3%), one client identified as Asian American (2.4%), and one client identified as Biracial (2.4%). The racial and ethnic backgrounds of the therapist population sample include: six Caucasian therapists (85.7%) and one Latin American therapist (14.3%). Materials This study used a self-report assessment, the Working Alliance Inventory Short form (WAI-S), as a form of measurement of the alliance for both therapists and clients. Horvath, who has shown the instrument s validity and reliability, developed the WAI (Horvath & Greenberg, 1989). The WAI-S consists of a 12-item measure to assess for bond, goals, and tasks (4 items each) in the therapeutic alliance. The goals portion refers to a mutual determination and agreement of the goals set in therapy; tasks refer to the manner in which the client and therapist will work in order to achieve the goals; and bond refers to the connection between both people. Two separate versions of the instrument were given to the appropriate party: WAI-T for therapists and WAI-C for clients. Participants were asked to respond to each statement regarding how they feel about his or her therapist or client. An example of an item on the client version measuring bond states, I feel that [therapist name] appreciates me. An item for therapists measuring goals states, We are working towards mutually agreed upon goals, and an item for clients measuring tasks states, We agree on what is important for me to work on. For each of the 12 items, the participant is asked to rate the frequency and accuracy of the statement in a 7-point scale ranging from 1 (never) to 7 (always). The instructions ask the participant to work at a quick pace in order to ensure that the responses reflect the first impressions of the participants. Procedure The clinician participants of the study were informed about the nature of the research and were given the opportunity to accept or decline participation. The client participants were also given a form stating the intentions of the research studies in the Alliance Lab prior to their initial visit. During that time, they decided to either accept or decline participation in the study. Following the completion of the first therapy session, the client and therapist were given the WAI-S and asked to fill it out based on that first session. The instruments were filled out privately, without the presence of the other person in order to prevent any influences on the responses. The participants were asked to place the completed WAI-S in an envelope and turn it into a staff member. Both the therapists and clients were made aware that the other individual would not have access to their responses in order to ensure honesty in the answers. The envelopes with the WAI-S data were then given to the researchers to evaluate the total score and the individual scores for the subscales. The independent variable of this study is racial and ethnic background, specifically the two levels being whether therapists and clients had similar or different racial and ethnic backgrounds. The other independent variable is gender (male and female). The dependent variables are the self-report total scores (out of 84) of the WAI-S for both the therapists and clients, including the scores of the three subscales (bond, goals, tasks). RESULTS A one-way independent analysis of variance (ANOVA) was conducted to evaluate the hypothesis that both therapist and client dyads (N=41) with similar racial and ethnic backgrounds would rate the therapeutic alliance higher, whereas therapists and clients with different backgrounds would rate the

6 51 alliance lower. This statistical analysis was chosen in order to determine the mean differences between groups on WAI scores for therapists and clients. The test for the therapists WAI total score was not significant, F(1,39) = 0.16, p=0.69. There was no significant difference in the therapists WAI total score for clients of a similar background (M=66.75, SD=7.96) or clients of a different background (M=67.71, SD=7.54), as shown in Table 1. Additionally, the test for the clients WAI total score was also not significant F(1,39) = 0.72, p=0.40. There was no significant difference in the clients WAI total score for those who had therapists of a similar background (M=70.05, SD=10.05) or therapists of a different background (M=72.57, SD=8.91), as seen in Table 2. There were no significant differences in the scores for each of the three subscales of the therapeutic alliance for either the therapists or clients. The results suggest that in therapist-client relationships, the similarity or difference in racial and ethnic background of the other person does not play a significant role in how either the therapist or client rate the therapeutic alliance. Post hoc analyses also looked for any effects that the gender of the therapist or client had on their ratings of the WAI. The normality assumption for parametric tests was validated, so the Mann-Whitney U test, a nonparametric analysis, was conducted in order to adjust for the uneven sample of male and female therapists. The analyses, as seen in Table 3, indicated that the WAI therapist total score was significantly greater for male therapists (M=71.27) than female therapists (M=65.77), U=94.00, p= When looking at the three separate subscales of the WAI (Table 4), the Mann-Whitney U test revealed that the WAI score for the tasks subscale was significantly greater for male therapists (M=23.91) than female therapists (M=21.03), U=73.50, p= The bond subscale score also approached significance when comparing male therapists (M=24.09) and female therapists (22.27), U=100.50, p= These results suggest that male therapists rated the therapeutic alliance higher than their female therapist counterparts. Neither male nor female clients reported any significant differences in how they rated the total therapeutic alliance or each of the three subscales. DISCUSSION Overall, the results of the study suggest that similarity or difference in racial and ethnic backgrounds do not significantly affect the therapeutic alliance between therapists and clients. Contrary to the original hypothesis, the findings show that therapists did not report any significant differences in the total score of the therapeutic alliance between racially and ethnically similar or different clients. Additionally, clients did not show any significant differences in their measure of the total score of therapeutic alliance with therapists of either similar or different backgrounds. However, the results did reveal that male therapists tend to rate the total score and tasks subscale for the therapeutic alliance higher than female therapists. Although the hypotheses of study were not validated, the results reveal important findings and implications in the context of the therapeutic alliance and cross-cultural therapy. The results show that there may be more factors playing a role in multicultural counseling than merely the racial and ethnic backgrounds of the therapists or clients. The results are important in that they suggest that the general majority or minority status of the dyads may not have as strong of an effect on the alliance that specific cultural or individual differences may have (Smith, Domenech Rodriguez, & Bernal, 2011).

7 52 There may be cultural differences within groups, such as cultural identity, upbringing, and acculturation of either the therapist or client. It is also important to look at the therapist s cultural competence and experience with counseling a client from a minority group or from a different culture than their own. These are all factors that can influence how cultural differences affect the therapeutic relationship (Smith et al., 2011). Previous research showed that clients receiving mental health treatment from a therapist of the same race had higher retention rates (Wintersteen et al., 2005). The results from Wintersteen et al s (2005) study are partially consistent with the results from this study. Their study found that Caucasian therapists rated their working alliance with clients of the same race higher than those of a different race, and therapists who were seeing a client from a different background rated the alliance significantly lower. However, similar to the current study, Wintersteen et al. (2005) also found that the alliance ratings of the clients were not significantly different for therapists of a similar or different race. This inconsistency may be attributed to the population sample being tested. While the first study was done with adolescent patients in substance abuse treatment, the current study used college students seeking mental health treatment through their university counseling center. It is important to note the difference in population because the clients in each setting may differ significantly in their mental health issues and other factors that can impact their experience in therapy. The current study did find, through post hoc analyses, that male therapists tended to rate the therapeutic alliance higher than female therapists. This finding suggests that the professional role and authority figure of the therapist could be a factor in the reason that male therapists rated the alliance higher (Shonfeld-Ringel, 2001). This may be attributed to a self-favoring bias in that male therapists may believe they are performing more favorably than their female counterparts. Moreover, the results suggest that it may be important to further investigate the effects that gender differences, rather than racial or ethnic differences, may have on the alliance since significant results were found when analyzing male and female therapists (Wintersteen et al., 2005). A limitation of the study is the small sample size used, especially the number of therapists. Future studies should attempt to increase the sample size in order to have a more accurate presentation of the population and to avoid any outliers. Additionally, there was also not a great deal of diversity in the therapist sample in this current study. The majority of the therapists identified as Caucasian, which is not an accurate portrayal of the racial and ethnic makeup of people in the United States. Therefore, a more diverse therapist population could reveal different effects in the results because clients would have a higher chance of receiving treatment from a racial or ethnic minority therapist. Although there were not significant differences found between similar or different racial and ethnic backgrounds for therapists and clients, it is important to note that this finding was based on the measurement of the therapeutic alliance through the WAI, which is based on self-report data. Self-report assessments can produce a misrepresentation of actual thoughts and opinions. The participant may feel the need to emphasize or minimize their responses in order to prevent embarrassing or uncomfortable revelations. The participants of self-report assessments may also respond to the items in a way that is favorable to themselves, or they may respond in a way they believe they are expected to respond. It is also important to consider that the WAI was administered to both the therapist and client after just the first session, which may not be a strong indicator or

8 53 predictor of what the alliance will be like throughout the entire therapy process. In order to address the limitations of a self-report assessment, there may be value in investigating how third-party observers rate the therapeutic alliance. By having an outside observer evaluate the relationship between therapists and clients of similar or different racial and ethnic backgrounds, we may be able to have a more objective viewpoint of the therapeutic alliance. Future research could use a form of evaluation similar to the WAI, in which an observer watches recorded videos of a therapy session and rates the alliance based on what he or she has observed. In addition, a coding system could be used to study differences in specific behaviors exhibited by therapists or clients of similar or diverse backgrounds. The findings provide future researchers with information to help uncover the reason for the underutilization and higher likelihood of dropout of minority clients in mental health services. CONCLUSION The current study has provided insight into the therapeutic alliance within the context of cross-cultural therapy. Although this study did not find any significant differences pertaining to the alliance and racial and ethnic differences in therapist-client dyads, the research has given direction to further research on the topic. Future research in this area of study can be useful in showing the importance of multicultural competence therapy in order to increase awareness and use of counseling services. Research investigating therapeutic factors, beyond the alliance, can be helpful in providing effective and positive mental health treatment for minority groups and diverse individuals. REFERENCES American Counseling Association. (2014). ACA Code of Ethics. Retrieved from counseling.org/resources/aca-code-of-ethics. pdf Asnaani, A., & Hofmann, S. G. (2012). Collaboration in Culturally Responsive Therapy: Establishing A Strong Therapeutic Alliance Across Cultural Lines. Journal of Clinical Psychology, 68(2), doi.org/ /jclp Brinson, J. A., & Kottler, J. A. (1995). Minorities underutilization of counseling centers mental health services: A case for outreach and consultation. Journal of Mental Health Counseling, 17(4), Carter, R. T., Yeh, C. J., & Mazulla, S. L. (2008). Cultural values and racial identity statuses among Latino students: An exploratory investigation. Hispanic Journal of Behavioral Sciences, 30, Chang, D. F., & Berk, A. (2009). Making cross-racial therapy work: A phenomenological study of clients experiences of cross-racial therapy. Journal of Counseling Psychology, 56(4), doi: /a Constantine, M. G. (2002). Predictors of satisfaction with counseling: Racial and ethnic minority clients attitudes toward counseling and ratings of their counselors general and multicultural counseling competence. Journal of Counseling Psychology, 49(2), doi: /

9 54 DeAngelis, Tori. (2015). In search of cultural competence. American Psychological Association, 46(3). Retrieved from monitor/2015/03/cultural-competence.aspx Horvath, A. O., Del Re, A. C., Flückiger, C., & Symonds, D. (2011). Alliance in individual psychotherapy. In J. C. Norcross (Ed.), Psychotherapy relationships that work (2nd ed., pp. 3-24). New York, NY: Oxford University Press. Horvath, A. O., & Greenberg, L. S. (1989). Development and validation of the Working Alliance Inventory. Journal of Counseling Psychology, 36(2), doi: / Maxie, A. C., Arnold, D. H., & Stephenson, M. (2006). Do therapists address ethnic and racial differences in cross-cultural psychotherapy? Psychotherapy: Theory, Research, Practice, Training, 43(1), doi: / Norcross, J. C., & Lambert, M. J. (2011). Evidencebased therapy relationships. In J. C. Norcross (Ed.), Psychotherapy relationships that work (2nd ed., pp. 3-24). New York, NY: Oxford University Press. Peluso, P. R., Miranda, A. O., Firpo-Jimenez, M. & Pham, M. (2010). Attachment dynamics and Latin cultures: Areas of convergence and divergence. In P. Erdman, K. Ng, and Metzger (Eds.) Cross-cultural perspectives of attachment: Theory, research, and clinical implications (pp ). New York: Routledge. Shonfeld-Ringel, S. (2001). A re-conceptualization of the working alliance in cross-cultural practice with non-western clients: Integrating relational perspectives and multicultural theories. Clinical Social Work Journal, 29(1), Smith, T. B., Rodríguez, M. D. and Bernal, G. (2011). Culture. In J. C.Norcross (Ed.), Psychotherapy relationships that work (2nd ed., pp. 3-24). NewYork, NY: Oxford University Press. U.S. Census Bureau (2015). New Census Bureau Report Analyzes U.S. Population Projections. Retrieved from newsroom/press-releases/2015/cb15-tps16. html Vasquez, M. J. T. (2007). Cultural difference and the therapeutic alliance: An evidence-based analysis. American Psychologist, 62(8), doi: / x Wintersteen, M. B., Mensinger, J. L., & Diamond, G. S. (2005). Do gender and racial differences between patient and therapist affect therapeutic alliance and treatment retention in adolescents? Professional Psychology: Research and Practice, 36(4), doi: /

10 55 APPENDIX Table 1 Means and Standard Deviations for WAI Therapist Total Score for therapist-client dyads of similar and different backgrounds Race/Ethn Mean (Out of 84) Std. Deviation N Same Different Total Table 2 Means and Standard Deviations for WAI Client Total Score for therapist-client dyads of similar and different backgrounds Race/Ethnicity Mean(Out of 84) Std. Deviation N Same Different Total Table 3 Mann-Whitney U Test for WAI Therapist Total Score looking at Therapist Sex WAITTOT Mann-Whitney U Wilcoxon W Z Asymp. Sig. (2-tailed).036 Exact Sig. [2*(1-tailed Sig.)].037 b Table 4 Mann-Whitney U Test for WAI Therapist Task, Bond, and Goal Scores looking at Therapist Sex WAITTASK WAITBOND WAITGOAL Mann-Whitney U Wilcoxon W Z Asymp. Sig. (2-tailed) Exact Sig. [2*(1-tailed Sig.)].006 b.057 b.226 b